Provider Demographics
NPI:1982193546
Name:ANDERSON, SAMANTHA JO (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4829
Mailing Address - Country:US
Mailing Address - Phone:408-813-0977
Mailing Address - Fax:
Practice Address - Street 1:107 S MADISON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4501
Practice Address - Country:US
Practice Address - Phone:408-813-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3145-57103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling